Dr.S. Sambath M.D D.CH

MADURAI.

DOS AND DONTS IN DENGUE FEVER

3 MANIFESTATIONS Probable dengueDengue with warning signsSevere dengue

3 PHASESFebrilecriticalRecovery

3 IMPORTANT ASPECTSAssessment - triageMonitoring - Clinical and LaboratoryTreatment - IV Fluids and Blood

3 PLANS of Mx –Plan A, B, C

Dengue Lab Diagnosis

RNA, Flaviviridae, Flavivirus Febrile phase 1 to 4 days

Genome - RT PCR - Highly sensitive

NS1 Ag – rapid test or ELISA Critical Phase 4 to 5 days

IgM mac ELISA or rapid on 5th day

IgM/IgG optical density ratio >1:2

IgG ratio >1/1280

Essential for good practicePLAN A -PROBABLE DENGUE

Patient from endemic area Fever (plus 2 of the following)

Anorexia with nausea

Rash

Aches and Pains

Leucopenia

Tourniquet test + ve no warning signs Laboratory features [hct ,platlet]

Plan A - Managed at home

Educate about warning signs Monitor urine output Administer ORS Avoid NSAID Treat fever - paracetamol 10 mg/kg Report in case of warning signs

immediately & follow up

PLAN B – DENGUE WITH WARNING SIGNS CLINICAL LABORATORY

Abdominal pain Persistent vomiting Lethargy,

Restlessness Mucosal bleed Liver enlargement >2

cm Clinical fluid

accumulation

Increased HCT Decreased platelet

count Progressive

leucopenia

Plan B -Dengue with warning signs-Mx Admit

Obtain reference HCT before IV fluids Give only NS,RL or Hartmann’s solution Start 5-7ml/kg/hr for 1-2 hrs (reassess)

3-5ml/kg/hr for 2-4 hrs(reassess)

2-3ml/kg/hr Reassess clinical status and HCT before

adjusting fluid therapy Minimum fluid to maintain urine output

0.5ml/kg/ hr

Monitoring

vitals &peripheral pulses 1-4 hrly

U/O 4-6 hrly

HCT before and after fluid therapy

Blood sugar, organ function(RFT,LFT ABG, etc)

Encourage oral fluids in high risk comorbid dengue pts

If HCT remains same or increase minimally& vitals stable

NS 2-3 ml/kg/hr for 2-4 hr then change to oral fluids

If HCT increases – vitals deteriorates

increase fluid to 5-10ml/kg for 1-2 hrs Ideally body weight is used for

calculating fluid infusion in obese patients

PLAN C Severe dengue compensated shock

Tachypnoea, mild retractions, air entry decreased HR increased, pulse volume decreased,

CRT>2sec,narrow pulse pressure<20mmHg Liver span increased Drowsy ,answers to questions

Management Administer O2 through jacksonrees circuit IV NS bolus 10ml/kg for 1 hr Check HCT , monitor U/O, Cardio-Respiratory-

Cerebral assessment

No shock with increased hematocrit

isotonic fluid 5-7ml/kg/hr for 1-2 hrs

3-5 ml/kg/hr for 2-4 hrs

2-3 ml/kg/hr for upto 48 hrs Shock with increased HCT

repeat NS bolus10-20ml/kg/hr

7-10 ml/kg/hr for 1-2 hrs Shock with decreased HCT

PRBC 5-10 ml/kg

Fresh blood 10-20 ml/kg

Plan C - Severe dengue-hypotensive shock

cold clammy skin ,pulse not felt -?,

CRT>2 sec, BP-?

Management Provide O2 through jacksonrees circuit IV bolus NS 20ml/kg over 15 min check HCT IV bolus NS 10ml/kg over 30min-1hr IV bolus NS 10ml/kg over 1hr

↑HCT with unstable vitals-bolus fluid ↑HCT with stable vitals- maintenance

fluid Severe h’ge-urgent blood transfusion No clinical signs of bleed- use colloid

solution ↓HCT with unstable signs - blood

transfusion ↓HCT with stable signs + u/o ↑ -

reduce iv fluid

Correct hypoglycemia,hyponatremia

hypocalcemia, hyperkalemia Hypovolemia with shock

metabolic acidosis

give - IV fluids alone Tissue hypoxia +lactic acidosis give

IV fluids + sodium bicarbonate Hyperchloremia- Hartmann or RL Septic screening

Shock persisting even after giving 40 to 60ml of bolus NS

BP low - Dopamine low dose Severe hypotension -Epinephrine HCT low, No CRT improvement

Blood transfusion Pedal edema + hepatomegaly, fluid

overload

minimal iv fluids+ Ionotropes

Colloids

No clear advantage Improves the cardiac index & Raises the

HCT faster( pulse pressure <10mm Hg) Dextran 40 binds with Von Willebrand factor Gelatin based – allergic reaction Hydroxy ethyl starch- Osmotic renal injury

Blood transfusion -indications

Melena with profound refractory shock Persistent metabolic acidosis with normal

BP with abdominal pain and tenderness Unstable vitals regardless of hematocrit

Decreased hematocrit inspite of 40-60 ml/kg of IV fluidDoubtful - 5 to 10 ml/kg of fresh whole blood

Defenite-10 to 20 ml/kg

Fluid overload when Prolonged higher rate of IV fluid

Hypotonic, Inappropriate Early – wt gain, large pleural effusion,

large ascites Late -- pulmonary edema, abdominal

compartment syndrome Occur both in critical &recovery phase.

Fluid overload

SignsRespiratory distressElevated JVPRhonchiPleural effusionTense ascitesPulmonary edemaIrreversible shock

Management Oxygen Strong pulse with warm extremities

Recovery phase○ Inj. frusemide 0.1 to 0.5 mg/kg bid or tid

Critical phase○ ↓ iv fluids , change to colloid

Shock+↑HCT +fluid accumulation-careful iv fluids-5ml/kg / hr- 1-2 hrs

Shock + normal HCT +excess fluid + BP↓-dopamine drip at low rate +fresh whole blood

ACUTE RESPIRATORY DISTRESS AND FAILURE

1. Kussmals breathing-severe metabolic acidosis with severe shock –prefer lying posture

2. volume overload- large pleural effusion and ascites – normal pulse & urine output

3. Acute pulmonary edema –[wheeze/rhonchi]

4. ARDS-persistent hypoxia

NON INVASIVE VENTILATION Life threatening hypoxemia Early pulmonary edema ARDS Mild metabolic acidosis

 

MECHANICAL VENTILATION Restlessness, confused Acute pulmonary edema + shock Fail to respond to non invasive ventilation

Agitations-Shock, Hepatic failure, Metabolic derangement, encephalopathy, cerebral edema

Occult bleeding - prolonged hypotensive shock, unexplained tachycardia, Metabolic acidosis, Decreased HCT

Death-Prolonged shock, massive bleed,

Fluid overload, Organ dysfunction

Discharge criteria No fever for 48 hrs Normal hemodynamic status and urine

output No vomiting No respiratory distress Normal HCT , Increasing platelet count

WHAT TO DO: Drop in platelet & rise in HCT are

essential for early diagnosis cases of dengue/DHF should be

observed every hr Timely IV therapy-isotonic crystalloid

solution can prevent shock/lessen its severity

The patient condition become worse despite of giving 20 ml/kg of NS for 1hr,replace crystalloid solution with colloid solution(dextran or plasma)

If improvement occurs reduce the speed from 10 ml/kg to 7ml/kg then 5ml/kg and finally 3ml/kg

In case of severe bleeding ,give Fresh blood transfusion 10-20ml/kg -2hr..then crystalloid10ml/kg- 30to60 min &reduce the rate

in case of shock give O2 For correction of lactic acidosis use

sodium bicarbonate + iv fluids

WHAT NOT TO DO Missed diagnosis at the frontline Misinterpretations of vitals signs Inadequate fluid intake &urine output Late recognition of prolonged & profound shock Too little or too much iv fluids Do not give aspirin or brufen for fever Avoid giving IV therapy before there is warning

signs Avoid giving blood transfusion unless indicated Do not change the speed of fluid so rapidly NG tube to determine concealed bleeding or to

stop bleeding is not recommended

THANKS A LOT FOR LISTENING